HOW ARE TIBIAL OPEN FRACTURES TREATED IN BRAZIL ? A CROSS-SECTIONAL STUDY

Although the tibia is the most commonly affected site in an open fracture(1,2,3), its treatment still remains controversial(4,5). A century and half ago, tibial open fractures were often treated with amputation, with a high probability of patients evolving to sepsis and death(6,7). Today, fracture stabilization with an intramedullary nail enables an early rehabilitation, minimizes hospitalization time and the number of postoperative complications. Due to the evolution of fixation methods for this kind of fracture, to the technological development, and studies addressing the use of antibiotics and the treatment of soft parts, prognosis for those experiencing this kind of fracture has improved a lot. It is well established that open fractures must be treated with surgical cleaning, debridement, fracture stabilization, antibiotics use and early coverage of soft parts (7). However, there are some variations regarding those concepts in literature, with the majority of controversial aspects being related to: the real surgical need for open, type-I fractures and gunshot fractures(8,9,10); the best irrigation product and pressure for surgical cleaning(11,12); the best moment for wound closure and coverage of soft parts(13,14,15); time of antibiotics use(16,17); and the best method for fracture stabilization(5). There are many methods for stabilizing those kinds of fractures, with external fixators, intramedullary nails and plates being mostly used. The clearest evidence in literature suggests the blocked intramedullary nail as the method of choice for stabilizing those fractures (5). However, a different reality is present in Brazil and in other developing countries. The high costs of implants, the lack of availability of equipment for emergency situations and the technical difficulties regarding use (learning curve) restrain the use of intramedullary nails. Thus, other methods such as external fixators, plates and plastered immobilization are still most commonly used. It is acceptable that open fractures treatment should be performed with cleaning and surgical debridement(7), with liquid soap(12) and low irrigation pressure(11). Wounds should be left opened, being performed a late primary closure, except in Gustillo’s type-I fractures(18,19), in which the wound primary closure may be performed(15,20,21). The best moment to reconstruct soft parts is between one and two weeks(13,14,22,23), and the use of antibiotics must be restricted to 24 hours for types I and II, and to 48-72 hours after the last surgical procedure for type III(16,17). The objective of this study is to verify how a Brazilian orthopaedist treats those fractures regarding: classification, surgical indication, cleaning method (irrigation product and pressure), fixation method, primary closure indications, time to reconstruct soft parts, and duration of antibiotics use.